Beneficial effects of terlipressin in prolonged pediatric cardiopulmonary resuscitation: a case series

OBJECTIVE: Arginine vasopressin was found in experimental and clinical studies to have a beneficial effect in cardiopulmonary resuscitation. The American Heart Association 2000 guidelines recommended its use for adult ventricular fibrillation arrest, and the American Heart Association 2005 guidelines noted that it may replace the first or second epinephrine dose. There is little reported experience with arginine vasopressin in cardiopulmonary resuscitation of children. Terlipressin, a long-acting analog of arginine vasopressin, has recently emerged as a treatment for vasodilatory shock in both adults and in children, but evidence of its effectiveness in the pediatric setting is sparse. The objective of this retrospective study is to describe our experience in adding terlipressin to the conventional protocol in children with cardiac arrest. DESIGN: Retrospective case series study. SETTING: An 18-bed pediatric critical care department at a university-affiliated tertiary care children's hospital. PATIENTS: Seven pediatric patients with asystole, aged 2 months to 5 yrs, who experienced eight episodes of refractory cardiac arrest and did not respond to conventional therapy. INTERVENTIONS: Addition of terlipressin to epinephrine during cardiopulmonary resuscitation of children. MEASUREMENTS AND MAIN RESULTS: Return of spontaneous circulation was monitored and achieved in six out of eight episodes of cardiac arrest. One patient died 12 hrs after return of spontaneous circulation, and four patients survived to discharge with no neurologic sequelae. CONCLUSIONS: The combination of terlipressin to epinephrine during cardiopulmonary resuscitation may have a beneficial effect in children with cardiac arrest. More studies on this drug's safety and efficacy in this setting are mandated.     

Vasopressin administered with epinephrine is associated with a return of a pulse in out-of-hospital cardiac arrest

OBJECTIVE: Recent data suggest that using vasopressin in combination with epinephrine (adrenaline) may improve treatment of out-of-hospital cardiac arrest. This study examined local experience with the combination of epinephrine and vasopressin administration. METHODS: Data were obtained from an urban, municipal emergency medical service that does not include vasopressin in its formulary. A physician is dispatched to the scene of all cardiac arrest patients treated by this system. Vasopressin could be administered in addition to epinephrine to subjects with out-of-hospital cardiac arrest by the on-scene physician. Demographic information, drug administration and return of pulses were abstracted from patient care records for a 1-year interval. Multivariate logistic regression was used to assess the relationship between vasopressin use and outcomes. RESULTS: During the study period, data were available for 298 subjects receiving epinephrine-only (n=231, 78%), a combination of 40 IU vasopressin and epinephrine (n=37, 12%) or no vasopressor drugs (n=30, 10%). Among patients receiving vasopressor drugs, pulse was restored for 74 subjects (28%), and 56 subjects (21%) had a pulse on arrival at the hospital. Return of pulses was associated with witnessed collapse, bystander CPR, and an initial ECG rhythm of ventricular fibrillation or tachycardia. Subjects receiving vasopressin and epinephrine were more likely to have a return of pulses during the resuscitation (LR: 2.73; 95% CI: 1.24, 6.03) and at hospital arrival (3.85; 1.71, 8.65) than subjects treated with epinephrine alone. CONCLUSIONS: There is an association between using vasopressin in combination with epinephrine and restoration of circulation after out-of-hospital cardiac arrest.     

Outcome from paediatric cardiac arrest associated with trauma

OBJECTIVE: To examine survival rates for paediatric trauma patients requiring cardiopulmonary resuscitation (CPR) in the pre-hospital setting, and to identify characteristics that may be associated with survival. DESIGN: Ten-year retrospective trauma database review. SETTING: An urban physician-led pre-hospital trauma service serving a population of approximately 7.5 million, in the United Kingdom. PATIENTS: Eighty paediatric trauma patients (15 years or less) who received pre-hospital resuscitation following cardiorespiratory arrest between July 1994 and June 2004. INTERVENTION: Pre-hospital cardiopulmonary resuscitation. MAIN OUTCOME MEASURE: Survival to hospital discharge. RESULTS: Eighty children met inclusion criteria for the study. Nineteen (23.8%) were discharged alive from the emergency department and seven children (8.75%) survived to hospital discharge. Of the seven survivors, one had spinal cord injury. Two suffered asphyxial injury associated with blunt trauma and three sustained hypoxic insults following drowning or burns/smoke inhalation. In one patient with known congenital cardiac disease the cause of cardiac arrest was likely to have been medical. CONCLUSION: This study confirms the poor outcome for children requiring pre-hospital CPR following trauma. However, the results are better in this physician-attended group than in other studies where physicians were not present. They also suggest that cardiac arrest associated with trauma in children has a better outcome than in adults. In common with adults treated in this system, those patients with hypovolaemic cardiac arrest did not survive (Ann Emerg Med 2006;48:240-4). A large proportion of the survivors suffered hypoxic or asphyxial injuries. Targeted aggressive out-of-hospital resuscitation in certain patient groups can produce good outcomes.     

Bolus thrombolytic infusion during prolonged refractory cardiac arrest of undiagnosed cause

Acute myocardial infarction (AMI) and pulmonary embolism (PE) account for about 70% of cardiac arrest. Although thrombolytic therapy is an effective therapy for both AMI and PE, it is not routinely recommended during cardiopulmonary resuscitation (CPR) for fear of life threatening bleeding complications. Numerous case reports and retrospective studies have suggested a beneficial effect of thrombolytics in cardiac arrest secondary to AMI and PE; however, we present a case of successful use of bolus thrombolytics during CPR in a patient with undifferentiated cardiac arrest (undiagnosed cause) after prolonged conventional resuscitation without success.     

Vasopressin combined with epinephrine during cardiac resuscitation: a solution for the future?

Epinephrine given during cardiopulmonary resuscitation (CPR) may cause beta-mimetic complications in the postresuscitation phase. Vasopressin may be an alternative vasopressor drug during CPR. A subgroup analysis of a large prospective CPR investigation and of retrospective CPR studies suggests that vasopressin may be especially beneficial when combined with epinephrine. Beneficial effects of adding vasopressin were observed in other catecholamine-refractory shock states as well, such as vasodilatory shock and haemorrhagic shock. In order to maximize effects of any vasopressor during CPR, rapid aggressive chest compressions must be ensured to maximize blood flow and to enable advanced cardiac life support drugs to reach the arterial vasculature. We suggest alternating injections of 1 mg epinephrine i.v. and 40 IU vasopressin i.v. every 3–5 minutes during CPR until spontaneous circulation can be achieved or CPR efforts are terminated.     

Vasopressin combined with epinephrine during cardiac resuscitation: a solution for the future?

Epinephrine given during cardiopulmonary resuscitation (CPR) may cause beta-mimetic complications in the postresuscitation phase. Vasopressin may be an alternative vasopressor drug during CPR. A subgroup analysis of a large prospective CPR investigation and of retrospective CPR studies suggests that vasopressin may be especially beneficial when combined with epinephrine. Beneficial effects of adding vasopressin were observed in other catecholamine-refractory shock states as well, such as vasodilatory shock and haemorrhagic shock. In order to maximize effects of any vasopressor during CPR, rapid aggressive chest compressions must be ensured to maximize blood flow and to enable advanced cardiac life support drugs to reach the arterial vasculature. We suggest alternating injections of 1 mg epinephrine i.v. and 40 IU vasopressin i.v. every 3–5 minutes during CPR until spontaneous circulation can be achieved or CPR efforts are terminated.     

Colon ischaemia and necrosis as a complication of prolonged but successful CPR

Survival after prolonged cardiopulmonary resuscitation (CPR) is often associated with neurological and other sequelae. We describe a patient who survived prolonged cardiac arrest due to ventricular fibrillation neurologically intact but suffered colon ischaemia and necrosis in the post-resuscitation period. Subtotal colectomy was performed. We wonder whether this complication was related to the use of vasopressin.     

Outcome of cardiopulmonary resuscitation in a pediatric cardiac intensive care unit

OBJECTIVE: To determine the eventual outcome of children with heart disease who had cardiopulmonary resuscitation (CPR) in a specialized pediatric cardiac intensive care unit (CICU), and to define the influence of any prearrest variables on the outcome. DESIGN: A retrospective review of patients' medical records. SETTING: A pediatric CICU of a tertiary pediatric teaching hospital. PATIENTS AND METHODS: Patients were all children who presented with cardiopulmonary arrest and who were administered CPR in the pediatric CICU between June 1995 and June 1997. Prearrest variables such as age, diagnosis, prior cardiac surgery, and inotropic support with epinephrine, as well as cause of arrest, were evaluated. MEASUREMENTS AND MAIN RESULTS: Thirty-two patients, ranging in age from 1 day to 21 yrs (median, 1 month), satisfied criteria for inclusion in the study group. These 32 patients had a total of 38 episodes of cardiopulmonary arrest. Twenty-five of these patients (78%) had cardiac surgery before arrest. Inotropic support with continuous infusion of epinephrine was being administered at the time of arrest in 18 of 38 (47%) arrests. These prearrest variables did not influence outcome of CPR. Of the 38 episodes of CPR, 24 episodes (63%) were successful, with 20 episodes resulting in return of spontaneous circulation and four patients being successfully placed on mechanical cardiopulmonary support. Fourteen children, including all four patients who were rescued with mechanical cardiopulmonary support, survived to discharge. At 6-month follow-up, 11 patients were still alive, with three having neurologic impairment. CONCLUSIONS: After cardiopulmonary resuscitation in this pediatric CICU, the rate of success was 63% and the rate of survival was 42%. Prior cardiac surgery and use of epinephrine before arrest did not influence the outcome of CPR. The availability of effective mechanical cardiopulmonary support can improve the outcome of CPR.     

体外心肺复苏技术在成人心搏骤停抢救中的应用

目的 回顾性总结应用体外心肺复苏(E-CPR)技术救治成人心搏骤停患者的临床经验.方法 2005年7月至2009年7月,有11例心源性心搏骤停成人患者(男7例,女4例,年龄24～71岁)经常规心肺复苏(CPR)抢救10～15 min无法有效恢复自主循环,而采用E-CPR技术抢救.7例心脏手术后患者在CPR抢救同时自原胸骨切口先建立升主动脉-右心房常规体外循环辅助,再转为体外膜肺氧合(ECMO)辅助;4例患者在CPR抢救同时直接经股动、静脉置管建立ECMO辅助.结果 11例患者CPR时间30～90 min,平均(51±14)min,10例患者可恢复自主心律.11例患者ECMO辅助时间2～223 h,中位时间126 h.6例患者成功撤离ECMO辅助,但存活出院率为36.4%(4/11).2例患者在ECMO辅助的同时加用主动脉内球囊反搏术(IABP),1例存活.3例患者因合并肾功能衰竭而需血液滤过治疗.结论 E-CPR为抢救危重的心搏骤停患者提供了一个新的手段.如何有效评估和选择病例,及时开始救治以提高成功率,值得进一步研究.     

Vasopressors in cardiac arrest: a systematic review

ObjectivesTo review the literature addressing whether the use of vasopressors improves outcomes in patients who suffer cardiac arrest.MethodsDatabases were searched using the terms: “(adrenaline or noradrenaline or vasopressor) and (heart arrest or cardiac arrest) and therapy”. Inclusion criteria were human studies, controlled trials, meta-analysis or case series. Exclusion criteria were articles with no abstract, abstract-only citations without accompanying article, non-English abstracts, vasopressor studies without human clinical trials, case reports, reviews, and articles addressing traumatic arrest.Results1603 papers were identified of which 53 articles were included for review. The literature addressed 5 main therapeutic questions. (1) Outcomes comparing any vasopressor to placebo. (2) Outcomes comparing vasopressin (alone or in combination with epinephrine) to epinephrine. (3) Outcomes comparing high dose epinephrine to standard dose epinephrine. (4) Outcomes comparing any alternative vasopressor to epinephrine. (5) Outcomes examining vasopressor use in pediatric cardiac arrest.ConclusionThere are few studies that compare vasopressors to placebo in resuscitation from cardiac arrest. Epinephrine is associated with improvement in short term survival outcomes as compared to placebo, but no long-term survival benefit has been demonstrated. Vasopressin is equivalent for use as an initial vasopressor when compared to epinephrine during resuscitation from cardiac arrest. There is a short-term, but no long-term, survival benefit when using high dose vs. standard dose epinephrine during resuscitation from cardiac arrest. There are no alternative vasopressors that provide a long-term survival benefit when compared to epinephrine. There is limited data on the use of vasopressors in the pediatric population.     

Adrenergic agonists during cardiopulmonary resuscitation

A number of studies have suggested that following a prolonged cardiopulmonary arrest, large doses of alpha-adrenergic agonists that possess post-synaptic alpha-2 agonist properties, i.e. epinephrine and norepinephrine, may be required to enhance myocardial and cerebral hemodynamics. While initial human studies using large doses of epinephrine have shown improved hemodynamics over standard therapy, hospital discharge rates and neurological outcome have been discouraging. This probably reflects the fact that the administration of epinephrine was employed late in the resuscitation effort. Future studies using larger doses of epinephrine as the initial pharmacologic intervention during cardiopulmonary resuscitation (CPR) will help to determine whether there is any therapeutic benefit. In addition, a number of questions still remain unanswered in delineating the specific alpha and beta adrenergic agonist components which will maximally enhance hemodynamics and resuscitation rates during CPR. This will help determine whether norepinephrine or a yet unsynthesized adrenergic agonist may be more beneficial for use during cardiac arrest.     

Vasopressin-mediated adrenocorticotropin release increases plasma cortisol concentrations during cardiopulmonary resuscitation

OBJECTIVE: Vasopressin is a possible stimulus for both adrenocorticotropin (ACTH) and endothelin-1 release. The aim of this study was to compare plasma concentrations of ACTH, cortisol, and endothelin-1 after epinephrine or vasopressin administration in an experimental animal model of cardiopulmonary resuscitation (CPR). DESIGN: Prospective, randomized, controlled animal study. SETTING: A university research laboratory. SUBJECTS: Fourteen 12- to 14-wk-old domestic pigs. INTERVENTIONS: After 4 mins of cardiac arrest and 3 mins of external chest compression, the pigs were randomly assigned to receive either 0.045 mg/kg epinephrine (n = 7) or 0.4 units/kg vasopressin (n = 7). At 5 mins after drug administration, defibrillation was attempted. MEASUREMENTS AND MAIN RESULTS: Coronary perfusion pressure, ACTH, cortisol, and endothelin-1 were measured before cardiocirculatory arrest, during CPR before drug administration, and at 90 secs and 5 mins after drug administration. Coronary perfusion pressure was comparable between groups. All seven animals in the vasopressin group survived, but only one pig in the epinephrine group survived (p = .005). ACTH and cortisol concentrations remained unchanged in epinephrine-treated animals, but increased significantly after vasopressin administration and were significantly higher than in epinephrine-treated animals 5 mins after drug administration. Endothelin-1 concentrations remained unchanged during the study period and were comparable between both groups. CONCLUSIONS: Vasopressin is a potent stimulus for ACTH secretion, but does not trigger endothelin-1 release from vascular cells during cardiac arrest and CPR. The increased plasma cortisol concentrations caused by the enhanced ACTH release after vasopressin may be one factor contributing to the improved outcome repeatedly observed with vasopressin in animal models of CPR.     

Thrombolysis in cardiopulmonary resuscitation

The prognosis of patients suffering cardiac arrest is still poor. Until today, no drug therapy has shown to improve longterm survival after cardiac arrest. Thrombolysis has been shown to be an effective therapy in patients with acute myocardial infarction (AMI) or massive pulmonary embolism (PE). Since 50-70% of cardiac arrests are caused by AMI or massive PE, the combination of cardiopulmonary resuscitation (CPR) and thrombolytic therapy appears to be sensible. As experimental studies have shown, thrombolytic therapy during CPR may not only be a causal treatment for coronary or pulmonary arterial obstruction by thrombi, but may also improve microcirculatory reperfusion after cardiac arrest. Although numerous small clinical studies have shown the efficacy of thrombolysis during CPR in selected patients, the generalized treatment of patients suffering cardiac arrest with thrombolytics can not be recommended based on current clinical evidence. According to the recent CPR guidelines, thrombolysis may be considered in cardiac arrest patients with suspected massive PE or as a so-called rescue therapy after unsuccessful conventional CPR in patients with a suspected thrombotic cause of cardiac arrest. The risk of severe bleeding complications following thrombolysis during CPR seems to be outweighed by the potential benefit of this therapy in selected patients.     

Outcomes following cardiopulmonary resuscitation in an acute rehabilitation hospital. Clinical and ethical implications.

This retrospective study examines cases of cardiac arrest requiring cardiopulmonary resuscitation (CPR) in an acute rehabilitation hospital. All admissions to the Center for Rehabilitation Medicine at Emory University, a 56-bed facility, are reviewed. Seventeen cases of true cardiac arrest are identified for analysis of ultimate disposition over a 10-yr period. Only one patient (5.9%) survived CPR to discharge from the rehabilitation hospital, but he died subsequent to his transfer to the acute hospital. Though the sample size is small, it reflects the total population of patients eligible for CPR who suffered a cardiac arrest. We conclude that CPR is generally not successful in the elderly inpatient rehabilitation population. The growing clinical complexity of the rehabilitation patient demands that health-care providers and their patients more regularly address decision-making issues pertinent to CPR.     

Recombinant tissue plasminogen activator during cardiopulmonary resuscitation in 108 patients with out-of-hospital cardiac arrest.

BACKGROUND: Thrombolytic therapy during cardiopulmonary resuscitation (CPR) is a controversial issue in emergency medicine practice. This study was conducted to determine whether administration of recombinant tissue plasminogen activator (rt-PA) in out-of-hospital cardiac arrest of non-traumatic aetiology improves CPR outcome. METHODS AND RESULTS: A retrospective chart review of 401 patients with out-of-hospital cardiac arrest who were resuscitated by the emergency medical services (EMS) during a 6 year period was performed. A total of 108 patients received rt-PA during CPR and were compared to 216 controls, closely matched according to baseline characteristics, arrival status and ECG findings. Administration of rt-PA was optional. Return of spontaneous circulation (ROSC) occurred in 76 patients under rt-PA treatment (70.4 vs. 51.0% in controls; P=0.001). Fifty-two patients from the lysis group survived the first 24 h (48.1 vs. 32.9% in controls; P=0.003), while 27 (25.9%) survived to discharge. Autopsy reports revealed major bleeding complications in six patients receiving rt-PA treatment. Fulminant intracranial haemorrhage was observed in one patient who received rt-PA and in two cases from the control group. CONCLUSIONS: Thrombolytic therapy may improve frequency of return of spontaneous circulation substantially and increase primary survival in patients with non-traumatic cardiac arrest. Serious bleeding complications are not frequently observed under rt-PA treatment.     

Effect of the Addition of Vasopressin or Vasopressin Plus Nitroglycerin to Epinephrine on Arterial Blood Pressure during Cardiopulmonary Resuscitation in Humans

Background: Infusion of a vasopressor during cardiopulmonary resuscitation (CPR) in humans increases end decompression (diastolic) arterial blood pressure, and consequently increases vital organ perfusion pressure and survival. Several vasoactive drugs have been tested alone or in combination, but their hemodynamic effects have not been investigated clinically in humans. Study Objective: We tested the hypothesis that epinephrine (1 mg) co-administered with vasopressin (40 IU) ± nitroglycerin (300 μg) results in higher diastolic blood pressure than epinephrine alone. Study Design: A prospective, randomized, double-blinded controlled trial in the prehospital setting. The study included 48 patients with witnessed cardiac arrest. Patients received either epinephrine alone (E alone) or epinephrine plus vasopressin (E+V) or epinephrine plus vasopressin plus nitroglycerin (E+V+N). A femoral arterial catheter was inserted for arterial pressure measurement. Outcome Measures: The primary end point was diastolic blood pressure during CPR, 15 min after the first drug administration (T = 15 min). Results: After exclusions, a total of 44 patients were enrolled. Diastolic blood pressures (mm Hg) at T = 15 min were not statistically different between groups (median [interquartile range]: 20 [10], 15 [6], and 15 [13] for E alone, E+V, and E+V+N, respectively. The rate of return of spontaneous circulation was 63% (n = 10) in the epinephrine group, 43% (n = 6) in the epinephrine plus vasopressin group, and 36% (n = 5) in the triple therapy group (NS). Conclusions: Addition of vasopressin or vasopressin plus nitroglycerin to epinephrine did not increase perfusion blood pressure compared to epinephrine alone in humans in cardiac arrest, suggesting the absence of benefit in using these drug combination(s).     

Diagnosis of aortic dissection by transesophageal echocardiography during cardiopulmonary resuscitation

ObjectivesEarly identification of the causes of cardiac arrest is helpful in determining the resuscitation measures during cardiopulmonary resuscitation (CPR). We aimed to evaluate the feasibility of transesophageal echocardiography (TEE) during CPR in diagnosing aortic dissection and the influence of aortic dissection on resuscitation outcome in adult patients with prolonged non-traumatic cardiac arrest.MethodsAdult patients aged >20 years with non-traumatic cardiac arrest who underwent prolonged CPR (>10 min) and TEE examination during CPR were enrolled. The enrolled patients were grouped according to the presence of aortic dissection on TEE: the aortic dissection (AD) group and the non-AD group. Variables related to cardiac arrest event, CPR, and resuscitation outcome were compared between the two groups.ResultsForty-five patients (median age, 71 years; 26 men) were enrolled. Ten (22.2%) and 35 (77.8%) patients were included in the AD and non-AD groups, respectively. No patients in the AD group survived. Aortic dissection on TEE was inversely related to the rate of return of spontaneous circulation on multivariate analysis (odds ratio, 0.019; 95% confidence interval, 0.001–0.750; p = .035).ConclusionTEE is a useful tool for diagnosing aortic dissection as a cause of cardiac arrest during CPR. Aortic dissection is associated with poor resuscitation outcomes.     

Outcomes of cardiopulmonary arrest in an acute rehabilitation setting

OBJECTIVE: Fifty consecutive cases of cardiopulmonary arrest with administration of cardiopulmonary resuscitation (CPR) during a 6-yr period at a freestanding academic acute rehabilitation hospital were identified. DESIGN: Medical records of 49 patients were available for review. Outcomes of survival of arrest, survival to 24 hr postarrest, survival to discharge from the hospital were determined, and chi2 or Fisher's exact tests were performed to investigate relationships between survival and admission functional status, age, gender, and medical comorbidities. RESULTS: Forty-three percent of patients survived the initial arrest, 37% survived to 24 hr post-CPR, and 18% survived to hospital discharge. We were unable to identify any statistically significant predictors of survival post-CPR. Six of the nine survivors returned to the acute rehabilitation setting after cardiopulmonary arrest, and five of these patients made significant functional gains. CONCLUSIONS: Outcomes after CPR in patients undergoing acute rehabilitation in one setting were not significantly different from those reported for patients in other healthcare settings. These data may be used by healthcare professionals to enhance discussions concerning advance healthcare planning (including resuscitation plans) with patients and families. Larger studies are needed to clarify the prognostic role of prior functional status in predicting CPR outcomes, particularly in the context of various diagnostic categories and age groups.     

Vasopressin improves vital organ blood flow after prolonged cardiac arrest with postcountershock pulseless electrical activity in pigs

OBJECTIVE: Although a benefit of vasopressin when compared with epinephrine was shown during cardiopulmonary resuscitation (CPR) after a short duration of ventricular fibrillation cardiac arrest, the effect of vasopressin during prolonged cardiac arrest with pulseless electrical activity is currently unknown. DESIGN: Prospective, randomized laboratory investigation using an established porcine model with instrumentation for measurement of hemodynamic variables, vital organ blood flow, blood gases, and return of spontaneous circulation. SETTING: University hospital laboratory. SUBJECTS: Eighteen domestic pigs. INTERVENTIONS: After 15 mins of cardiac arrest and 3 mins of chest compressions, 18 animals were randomly treated with either 0.8 units/kg vasopressin (n = 9) or 200 microg/kg epinephrine (n = 9). MEASUREMENTS AND MAIN RESULTS: Compared with epinephrine, vasopressin resulted, at both 90 secs and 5 mins after drug administration, in significantly higher (p < .05) median (25th-75th percentiles) left ventricular myocardial blood flow (120 [range, 96-193] vs. 54 [range, 11-92] and 56 [range, 41-80] vs. 21 [range, 11-40] mL/min/100 g, respectively) and total cerebral blood flow (85 [78-102] vs. 24 [18-41] and 50 [44-52] vs. 8 [5-23] mL/min/100 g, respectively). Spontaneous circulation was restored in eight of nine animals in the vasopressin group and in one of nine animals in the epinephrine group (p = .003). CONCLUSIONS: Compared with a maximum dose of epinephrine, vasopressin significantly increased left ventricular myocardial and total cerebral blood flow during CPR and return of spontaneous circulation in a porcine model of prolonged cardiac arrest with postcountershock pulseless electrical activity.     

A randomised, double-blind, multi-centre trial comparing vasopressin and adrenaline in patients with cardiac arrest presenting to or in the Emergency Department

ObjectiveTo compare vasopressin and adrenaline in the treatment of patients with cardiac arrest presenting to or in the Emergency Department (ED).DesignA randomised, double-blind, multi-centre, parallel-design clinical trial in four adult hospitals.MethodEligible cardiac arrest patients (confirmed by the absence of pulse, unresponsiveness and apnea) aged >16 (aged > 21 for one hospital) were randomly assigned to intravenous adrenaline (1 mg) or vasopressin (40 IU) at ED. Patients with traumatic cardiac arrest or contraindication for cardiopulmonary resuscitation (CPR) were excluded. Patients received additional open label doses of adrenaline as per current guidelines. Primary outcome was survival to hospital discharge (defined as participant discharged alive or survival to 30 days post-arrest).Main resultsThe study recruited 727 participants (adrenaline = 353; vasopressin = 374). Baseline characteristics of the two groups were comparable. Eight participants (2.3%) from adrenaline and 11 (2.9%) from vasopressin group survived to hospital discharge with no significant difference between groups (p = 0.27, RR = 1.72, 95% CI = 0.65–4.51). After adjustment for race, medical history, bystander CPR and prior adrenaline given, more participants survived to hospital admission with vasopressin (22.2%) than with adrenaline (16.7%) (p = 0.05, RR = 1.43, 95% CI = 1.02–2.04). Sub-group analysis suggested improved outcomes for vasopressin in participants with prolonged arrest times.ConclusionsCombination of vasopressin and adrenaline did not improve long term survival but seemed to improve survival to admission in patients with prolonged cardiac arrest. Further studies on the effect of vasopressin combined with therapeutic hypothermia on patients with prolonged cardiac arrest are needed.